Innovation Implementation:
In order to reduce readmission rates among the hospital’s heart failure patients, the multi-disciplinary team members working at Medina Hospital realized they needed to target interventions earlier in the stay, when patients are first admitted. However, the team discovered that they could automatically generate a true, real-time list of heart failure patients through their electronic medical record (EMR) system and were wasting valuable time. Working with the more experienced EPIC-user members of their interdisciplinary team, the team was able to develop a temporary workaround that combined patient data from its EMR, EPIC, and information entered by the attending physicians in the hospital’s CPOE system (computerized provider order entry). Pulling these data sets helped create a readmissions database that allowed staff to review which patients were in the hospital and why. Next, the team at Medina set up a new workflow process to target heart failure patients with education to avoid a readmission to the hospital. The workflow process involved:

Nurses who employed the ‘teach back’ method to ensure patients understood the importance of weighing themselves, avoiding certain foods and recognizing early signs when their condition was worsening.

Clinical pharmacist who educated patients about each medication and the side effects.

Care advocate who made sure patients understood their plan of care including scheduling a follow-up appointment with their primary care physician after discharge.

With the new database and improved workflow processes in place, the multidisciplinary hospital team was able to reduce the 30-day all cause heart failure readmission rate by 9 percent.